FUNGAL INFECTION Amanda Kozlik Chelsea Thompson Farbod Khaleghi - - PowerPoint PPT Presentation

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FUNGAL INFECTION Amanda Kozlik Chelsea Thompson Farbod Khaleghi - - PowerPoint PPT Presentation

Nov 13, 2022 406 likes •869 views

FUNGAL INFECTION Amanda Kozlik Chelsea Thompson Farbod Khaleghi Lisa DAngelo Nestor Otero PATIENT PRESENTATION HPI: WM is a 66 y/o male who initially presented to the hospital for an upper GI bleed in September. The pt. had to be

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SLIDE 1

FUNGAL INFECTION

Amanda Kozlik Chelsea Thompson Farbod Khaleghi Lisa D’Angelo Nestor Otero

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SLIDE 2

PATIENT PRESENTATION

  • HPI: WM is a 66 y/o male who initially presented to the

hospital for an upper GI bleed in September. The pt. had to be intubated and his admission was complicated by concurrent Providencia stuarti pneumonia, esophagitis, intermittent fevers and the presence of yeast on a blood culture. He was seen by ID, treated for 2 wks for Candida glabrata fungemia and had his IJ Perm-A-Cath removed. He was discharged from the hospital off of all antibiotics/antifungals as he had completed his course of antibiotics and micafungin.

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SLIDE 3

PATIENT PRESENTATION

  • PMH:
  • Cognitive impairment

with anoxic metabolic brain injury (since 2012)

  • Type 1 DM
  • End Stage Renal Disease
  • Anemia in CKD

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  • Agitation
  • GI bleed secondary

to esophagitis

  • Providencia stuarti

pneumonia

  • Candida glabrata

fungemia

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SLIDE 4

PATIENT PRESENTATION

  • Allergies: no known allergies
  • ROS: unable to be completed; pt. seems to be at

baseline mental status where he turns his head to his name, but is not really verbal or interactive

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SLIDE 5

PATIENT PRESENTATION

  • Medication List:
  • Lorazepam 0.5 mg PO daily PRN
  • Famotidine 20 mg PO BID
  • Sevelamer 800 mg PO TID with meals
  • Darbepoetin 60 mcg/mL SQ weekly on

Tuesday

  • Midodrine 5 mg PO daily PRN prior to

dialysis

  • Docusate 100 mg/10 mL PO BID
  • Bisacodyl 10 mg suppository rectally daily

PRN

5

  • Heparin 5000 units SQ TID
  • Calcitriol 0.25 mg PO daily
  • Insulin NPH 12 units SQ QAM and 14 units

SQ QHS

  • Insulin aspart 2 units SQ TID 5-15 mins

before meals

  • Hold if NPO
  • If BG: < 70, give 0 units; 71-99, 3 units;

100-140, 5 units; 141-180, 6 units; 181-220, 7 units; 221-260, 8 units; 261-300, 9 units; 301-340, 10 units; > 341, call MD

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SLIDE 6

PATIENT PRESENTATION

  • Hospital Course: On 11/17, WM returned to the ER where he was found to

be tachypneic, hypotensive and less responsive with a white count of 28.7, lactate of 3 and glucose level of 666.

  • His presentation was initially concerning for meningitis due to complaints of stiff
  • neck. He was given IV ceftriaxone, vancomycin and fluids and admitted to the
  • ICU. No further ABX were given since there was no clear source of infxn;

lumbar puncture was not performed.

  • Radiology (performed 11/17):
  • Brain CT w/o contrast: no acute abnormalities
  • Chest x-ray: patchy airspace disease in left lung, which has been there since

time of last admission (no significant changes since then)

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SLIDE 7

PATIENT PRESENTATION

  • Hospital Course: On 11/23, WM was weaned off the vent and transferred out of the
  • ICU. Central line is now out. Pt. has PEG tube for feeding. ID recommended removing

the right groin femoral line, obtaining a TTE & additional ophthalmology exam and consulting pharmacy.

  • Since then, preliminary reports of both sets of blood cultures have returned.
  • Cultures (collected 11/23):
  • Blood Cultures (right arm): preliminary reports from 11/24 show 4/4 bottles growing

Candida glabrata

  • Blood Cultures (right arm): preliminary reports from 11/25 show 1/4 bottles growing

Gram Positive Cocci

  • Pharmacy Consult (11/25) — recommending levofloxacin for GPCs

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SLIDE 8

LABS

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Timeline of WBC Levels Timeline of Temperature

11/23: 12.9 11/17: 28.7 11/24: 11.4 11/25: 13.4

11/17 PM: 98.1°F 11/22 PM: 102°F 11/23 AM: 97.8°F

11/23 PM: 101.6°F 11/25 AM: 101.4°F

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SLIDE 9

OTHER LABS

  • SCr was elevated upon admission:
  • SCr 7.9 (on 11/17) → 2.0 (on 11/23)
  • CBC confirms anemia due to CKD:
  • Hgb, Hct: 9.8, 29.9% (on 11/25)
  • CrCl = 28.7 mL/min (dialysis MWF)

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SLIDE 10

PHYSICAL EXAMINATION (11/25)

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VS: T 101.4ºF, P 95, RR 18, BP 122/60, Ht. 66 in., Wt. 123 lb., O2 97% (RA) Gen: chronically ill, nontoxic, turns head to voice, in NAD HEENT: anicteric sclera, pale conjunctiva, dry mucus membranes CV: RRR Lungs: clear Abd: soft, NT, G-tube is in place Neuro: tracks with his eyes, turns to voice, does not follow any commands

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SLIDE 11

PROBLEM LIST

  • 1. Candida glabrata fungemia
  • 2. Inappropriate levofloxacin recommendation
  • 3. Inappropriate renal dosing

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SLIDE 12

PROBLEM #1: FUNGEMIA

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SLIDE 13

ASSESSMENT

  • Initial Assessment:
  • WM has a history of Candida glabrata fungemia
  • Pt. is febrile (T 101.4°F) with leukocytosis (WBC 13.4)
  • Medications:
  • Previously received a 2-week course of micafungin for

the Candida glabrata fungemia in September

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SLIDE 14

PERTINENT +/-

  • Pertinent Positives:
  • Fever 101.4°F
  • HR 95
  • WBC 13.4
  • BP 122/60
  • 4/4 bottles growing Candida glabrata
  • Pertinent Negatives:
  • Pt. is normotensive and pulse is WNL

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SLIDE 15

GOALS OF THERAPY

  • Promptly recognize and treat fungemia without

delay (within 12 hours) upon receipt of positive blood cultures

  • Eradicate presence of Candida glabrata in blood
  • Minimize adverse effects of anti-fungal therapy
  • Reduce risk of mortality

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SLIDE 16

RISK FACTORS

  • Risk Factors for Invasive Candidiasis with Candida glabrata:
  • Recent antibiotic/antifungal use
  • Foreign devices (i.e. chemo port, central venous cath)
  • Neutropenia
  • Receiving parenteral nutrition
  • Sepsis
  • Mechanical ventilation
  • ICU stay
  • Hemodialysis

16 Leon C, et al. Crit Care Med. 2006; 34: 730-737. Gupta A, et al. Indian J Crit Care Med. 2015; 19(3): 151-154.

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SLIDE 17

SEPSIS

  • WM meets 3 SIRS criteria:
  • T > 38°C → WM: 101.4°F
  • HR > 90 → WM: 95
  • WBC > 12,000/mm

3 → WM: 13,400/mm 3

  • BP is stable, so no new interventions are needed at this time
  • BP & Temp should continue to be monitored to assess any

hemodynamic instability

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SLIDE 18

TREATMENT APPROACH

  • Until susceptibilities return, an appropriate antifungal

with coverage for Candida glabrata should be selected

  • 2009 IDSA Guidelines → “For infection due to

Candida glabrata, an echinocandin is preferred. (B-III)”

  • Echinocandin Options: Caspofungin, Micafungin,

Anidulafungin

18 Pappas PG, et al. Clin Infect Dis. 2009; 48(5): 503-535.

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SLIDE 19

TREATMENT APPROACH

19 Pappas PG, et al. Clin Infect Dis. 2009; 48(5): 503-535.

  • Azoles → variable susceptibility
  • Flucytosine → susceptible, but reserved for invasive endocarditis or meningitis
  • Amphotericin B → variable susceptibility
  • Echinocandins → 1st line for C. glabrata
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SLIDE 20

ECHINOCANDINS

  • Administration: IV once daily
  • Metabolism: minimal hepatic metabolism
  • Elimination: non-enzymatic degradation
  • None of the echinocandins are renally adjusted

in patients with renal insufficiency or dialysis

20 Pappas PG, et al. Clin Infect Dis. 2009; 48(5): 503-535.

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SLIDE 21

ECHINOCANDINS

  • As a class, echinocandins have relatively mild adverse effects
  • Common Adverse Effects:
  • GI upset (N/V/D)
  • Thrombocytopenia
  • Headache
  • Fever

21 Pappas PG, et al. Clin Infect Dis. 2009; 48(5): 503-535.

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SLIDE 22

PAPPAS PG, ET AL.

22 Pappas PG, et al. Clin Infect Dis. 2007; 45(7): 883-893.

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SLIDE 23

PAPPAS PG, ET AL.

  • Background: international, randomized, double-blind trial
  • Setting: 595 patients in North America, Europe, Brazil & India

assigned in 1:1:1 ratio to receive one of the following interventions

  • Possible Interventions:
  • Micafungin 100 mg IV once daily
  • Micafungin 150 mg IV once daily
  • Caspofungin 70 mg IV (Day 1) then 50 mg IV once daily

23 Pappas PG, et al. Clin Infect Dis. 2007; 45(7): 883-893.

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SLIDE 24

PAPPAS PG, ET AL.

  • Inclusion Criteria:
  • Candidemia (≥ 1 positive blood culture with Candida organisms)
  • At least 1 of following: T ≥ 38°C or < 36°C, SBP < 90, s/sx of inflammation, x-ray findings

suggesting invasive Candidiasis

  • Exclusion Criteria:
  • Pregnant/nursing
  • Liver disease
  • Life expectancy < 5 days
  • Candida endocarditis, osteomyelitis, meningitis
  • Receipt of cyclosporin or echinocandin within past month

24 Pappas PG, et al. Clin Infect Dis. 2007; 45(7): 883-893.

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SLIDE 25

PAPPAS PG, ET AL.

25 Pappas PG, et al. Clin Infect Dis. 2007; 45(7): 883-893.

Groups Treatment Success Time to Negative Culture Micafungin 100 mg 76.4% 2 days Micafungin 150 mg 71.4% 3 days Caspofungin 72.3% 2 days

Most appropriate option: micafungin 100 mg IV once daily

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SLIDE 26

SUMMARY

  • Micafungin is an appropriate choice for WM’s

candidemia

  • Micafungin requires specific monitoring

parameters due to possible adverse effects

  • Refer for ophthalmology consult to rule out

Candidal endophthalmitis

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SLIDE 27

PROBLEM #2: INAPPROPRIATE LEVOFLOXACIN RECOMMENDATION

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SLIDE 28

ASSESSMENT

  • Initial Assessment:
  • Preliminary reports of blood cultures (from

11/25) show 1/4 bottles growing Gram Positive Cocci

  • Pharmacy recommended levofloxacin

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SLIDE 29

PERTINENT +/-

  • Pertinent Positives:
  • 1/4 bottles growing Gram Positive Cocci
  • Pertinent Negatives:
  • VS are WNL

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SLIDE 30

GOALS OF THERAPY

  • Ensure antibiotics are being utilized appropriately

for a specific indication

  • Prevent collateral damage from unnecessary

antibiotic use

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SLIDE 31

TREATMENT APPROACH

  • The presence of Gram Positive Cocci in only 1 of the

4 bottles indicates it is likely a contamination due to Staph epidermidis

  • Gram (+) Cocci in clusters
  • Catalase (+)
  • Coagulase (-)

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SLIDE 32

TREATMENT APPROACH

  • Await culture results to confirm contamination

with Staph epidermidis

  • Levofloxacin therapy is not indicated for WM at

this time

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SLIDE 33

PROBLEM #3: INAPPROPRIATE RENAL DOSING

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SLIDE 34

ASSESSMENT

  • Initial Assessment:
  • WM has ESRD on HD
  • SCr 7.9 (on 11/17) → 2.0 (on 11/23)
  • CrCl = 28.7 mL/min (dialysis MWF)
  • Medications:
  • Famotidine 20 mg PO BID
  • Darbepoetin 60 mcg/mL SQ weekly on Tuesday

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SLIDE 35

PERTINENT +/-

  • Pertinent Positives:
  • SCr 2.0, BUN 19
  • Pt. receives hemodialysis 3 times/week via pulsatile left

upper extremity fistula

  • Pertinent Negatives:
  • Elevated SCr & BUN improved from admission
  • Mental status has improved to baseline since admission

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SLIDE 36

GOALS OF THERAPY

  • Manage WM’s illnesses with most appropriate

therapeutic dosing regimen possible

  • Prevent toxicity associated with improper renal

dosing of medications

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SLIDE 37

FAMOTIDINE

  • WM is currently taking → Famotidine 20 mg PO BID

for stress ulcer prophylaxis

  • Appropriate indication ✓
  • Appropriate dose ❌
  • If CrCl < 50 mL/min → give 50% of dose or

increase dosing interval to 36-48 hours

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SLIDE 38

DARBEPOETIN

  • WM is currently taking → Darbepoetin 60 mcg SQ

weekly (on Tuesday) for anemia due to CKD

  • Appropriate indication ✓
  • Appropriate dose ❌
  • If on dialysis → give 0.45 mcg/kg SQ once weekly

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SLIDE 39

SUMMARY

  • Adjust dosing of famotidine and darbepoetin to prevent

toxicity due to accumulation of these drugs and their metabolites

  • Adverse effects of famotidine: rhabdomyolysis, interstitial

pneumonia, seizure, constipation, headache, dizziness

  • Adverse effects of darbepoetin: hypotension, MI,

peripheral edema, CHF, angina

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SLIDE 40

PLAN

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SLIDE 41

PLAN - FUNGEMIA

  • Initiate micafungin 100 mg IV once daily x 14 days after first negative

blood culture and resolution of s/sx of candidemia

  • Counsel on possible adverse effects: N/V/D, headache
  • Monitor VS, CBC with diff, and Chem 7 (SCr, BUN) Q12 hrs
  • Monitor LFTs when initiating therapy & Q24 hrs
  • Removing the right groin femoral line
  • Obtain a TTE
  • Refer for ophthalmology consult to rule out Candidal endophthalmitis

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SLIDE 42
  • Await culture results to confirm presence of Staph

epidermidis

  • This suggests that the Gram Positive Cocci are

most likely a contamination vs. true infection

  • As a result, levofloxacin therapy is not

appropriate for WM at this time

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PLAN - INAPPROPRIATE RECOMMENDATION

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SLIDE 43

PLAN - INAPPROPRIATE DOSING

  • Decrease famotidine dose to 10 mg PO BID
  • Monitor for s/sx of stress ulcers and upper GI bleeding
  • Decrease darbepoetin dose to 25 mcg SQ once weekly on Tuesday
  • Monitor CBC (Hgb & Hct) weekly following adjustment of therapy

until stable

  • Hgb should not increase by > 1 g/dL in any 2 wk period
  • Monitor BP continuously via BP cuff

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SLIDE 44

REFERENCES

  • Gupta A, Gupta A, Varma A. Candida glabrata candidemia: An emerging threat

in critically ill patients. Indian J Crit Care Med. 2015; 19(3): 151-154.

  • Leon C, Ruiz-Santana S, Saavedra P

, et al. A bedside scoring system (Candida score) for early anti fungal treatment in non-neutropenic critically ill patients with Candida colonization. Crit Care Med.2006; 34: 730-737.

  • Pappas PG, Kauffman CA, Andes D, et al. Clinical Practice Guidelines for the

Management of Candidiasis: 2009 Update by the Infectious Diseases Society

  • f America. Clin Infect Dis. 2009; 48(5): 503-535.
  • Pappas PG, Rotstein CM, Betts RF, et al. Micafungin versus caspofungin for

treatment of candidemia and other forms of invasive candidiasis. Clin Infect Dis. 2007; 45(7): 883-893.

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SLIDE 45

THANK YOU

  • Any Questions?

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